Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare Of South Louisville during CMS and state inspections, most recent first.
Food service safety standards were not followed when dented canned goods were found in storage and on the can rack, including cans of chicken, fruit, soup, and vegetable juice with dents on the seals or sides. Staff described a new worker learning the kitchen process, and a staff member stated dented cans were screened and placed in a dented can room, while the DON said dented cans should be thrown out immediately. During lunch tray plating, staff also failed to perform hand hygiene.
A resident admitted with obstructive sleep apnea had admission orders for CPAP/BiPAP use, cleaning, head-of-bed elevation, and tubing changes, but the 48-hour baseline care plan did not include the CPAP device. RN staff, the Unit Manager, the MDS Coordinator, the DON, and the Administrator all confirmed that respiratory equipment present on admission should have been included in the baseline care plan.
Failure to Maintain Ordered Pressure-Relieving Cushion A resident with pressure ulcers, incontinence, malnutrition, and impaired mobility had an order for an air-cell wheelchair cushion, but the order did not appear on the MAR and the cushion was not consistently in place. Surveyors observed the resident sitting in a wheelchair with no cushion, and later with a different cushion than the one ordered. Staff interviews indicated the cushion was sometimes removed during wheelchair cleaning, the order may not have been entered correctly, and nurses were expected to verify that the ordered cushion was present.
Medication storage was not maintained properly when a resident’s povidone iodine wound care medication was found on the bedside table in the room instead of being locked in the treatment cart. Staff, including an RN, LPN, and the DON, stated the solution was a medication and should not have been left in the room. In addition, a medication cart had loose pills, pill debris, and trash in the drawers, and staff stated the cart was too tightly packed and should have been kept clean and organized.
A resident with chronic respiratory conditions was observed receiving supplemental oxygen at a rate higher than the physician-ordered 3 liters per minute. Nursing staff failed to consistently monitor and adhere to the prescribed oxygen rate, and there was no documentation of notifying the physician about the change. The facility's Director of Nursing and CEO acknowledged the need for adherence to physician orders.
The facility failed to maintain a medication error rate below 5%, with two errors out of 34 opportunities, resulting in a 5.88% error rate. A resident with type 2 diabetes was affected when RN 7 administered Lantus insulin without performing a safety test and Humalog insulin without priming the pen, contrary to manufacturer's instructions. Interviews revealed a lack of adherence to guidelines, with staff not following proper procedures for insulin administration.
A resident with type 2 diabetes mellitus received incorrect insulin dosage documentation by an LPN, who recorded dosages that did not match the physician's order of 35 units. The LPN admitted to entering wrong dosages due to interruptions, despite knowing the correct dose. The facility's policy required accurate charting and adherence to physician orders, which was not followed in this case.
A facility failed to ensure proper infection control practices for a resident on enhanced barrier precautions (EBP). The resident, with a surgical incision and indwelling catheter, required staff to wear a gown and gloves during care. However, a CNA was observed using only gloves while emptying the resident's catheter bag. Interviews with the CNA, DON, and CEO confirmed the expectation for full PPE use, highlighting a lapse in adherence to infection control policies.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During observation of the kitchen dry storage area, a 4-pound can of chunk light chicken in water was found dented on the top and bottom, and cans of classic apple and mandarin oranges were also observed with dents on the top seal and on the top and bottom seals. The Dietary Manager stated a new staff member had started the previous week, had never worked in the kitchen, and was learning the process, and that regular staff should check cans before they were put out, although new staff may not have been checking them for dents as they should have been. A later observation of the can storage rack found three 50-ounce cans of tomato soup dented at the seal, one 50-ounce can of cream of chicken soup dented at the seal, and one 46-ounce can of vegetable juice dented on the side, all available in storage. [NAME] #3 stated that staff screened canned food items for dents when the delivery truck arrived and put them in the dented can room, and also stated the vegetable juice can date was the date it came in. [NAME] #3 stated the dented can could not be used or given to a resident because they may get sick. During a separate observation of the lunch meal tray line, staff failed to practice hand hygiene while plating meals. The DON stated she expected dented cans to be thrown out immediately, and the Administrator stated dented cans should be separated and checked for safety and not used for any meal preparation.
Baseline Care Plan Missing CPAP Instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective, person-centered care for one resident with respiratory services. Resident 76 was admitted with diagnoses including obstructive sleep apnea and had admission orders for CPAP/BiPAP use daily from 6:00 PM to 6:00 AM, removal and cleaning of the mask/equipment each morning, head of bed elevation to alleviate shortness of breath while lying flat, and monthly tubing changes. The resident’s admission observation also listed CPAP under respiratory devices. Review of the resident’s 48-hour baseline care plan showed that it did not include the resident’s CPAP device use. During interviews, RN staff, the Unit Manager, the MDS Coordinator, the DON, and the Administrator all confirmed that respiratory equipment such as CPAP should have been included in the baseline care plan when it was present on admission and ordered at admission, and they confirmed that it was not included for this resident.
Failure to Maintain Ordered Pressure-Relieving Cushion for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received care consistent with professional standards of practice to promote healing. Resident #84 was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, need for assistance with personal care, and protein-calorie malnutrition. The resident’s MDS indicated intact cognition, partial to moderate assistance with transfers, bowel and bladder incontinence, risk for pressure ulcers, existing unhealed pressure ulcers, and one unstageable pressure ulcer. The care plan identified a sacral pressure ulcer and directed staff to use pressure-reducing devices, including a mattress and a wheelchair cushion. The resident had an order dated 01/16/2026 for a brand-name air-cell based cushion to be used in the wheelchair every shift day and night, but the February MAR did not include transcription of that order. A PT note documented that the wheelchair cushion had been changed to the air-cell based cushion to improve sitting tolerance, and nurse practitioner progress notes repeatedly stated the resident was on a chair cushion because of high risk for pressure ulcer formation. However, observations on 02/23/2026 and 02/24/2026 showed the resident sitting in a wheelchair without any cushion in place. On 02/25/2026, a cushion was observed in the chair, but it was not the ordered air-cell based cushion. Staff interviews showed the cushion was not consistently in place and the order was not reliably entered or tracked. The family member stated they had brought in a cushion from home and did not know why the resident did not have a cushion in the wheelchair. CNA staff stated the resident had always had a cushion, but they did not document whether cushions were in place. The LPN stated the ordered cushion should appear on the MAR and nurses should check daily that the resident had the ordered cushion. The wound care RN stated she usually implemented pressure ulcer orders and placed cushions in the resident’s room, but also said the order may have been a data entry error and that staff sometimes removed the cushion when cleaning the wheelchair and it did not always make it back. The DON and Administrator stated they expected the ordered pressure-reducing cushion to be in place and that orders should appear on the MAR for nurses to verify.
Medication Storage and Cart Housekeeping Deficiencies
Penalty
Summary
Medication was not securely stored for Resident #22, who was admitted with diagnoses including atherosclerosis of native arteries of the extremities with ulceration and type 2 diabetes mellitus. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 12, risk for pressure ulcers/injuries, and three venous or arterial ulcers. The care plan addressed an arterial ulcer to the left third toe, and physician orders included povidone iodine 10% solution for daily application to the third toe arterial ulcer and the left great toe arterial ulcer, as well as wound care instructions to cleanse the left third toe ulcer and paint it with povidone iodine as needed. During a concurrent observation and interview, six opened bottles of povidone iodine 10% solution with residual stains were observed on the resident’s bedside table. Additional observations showed a 16 fl oz bottle of povidone iodine on the bedside table and, later, another bottle still on the bedside table. RN #13 stated the bottle was a medication and should have been stored in the treatment cart. LPN #14 stated wound care supplies, including povidone iodine, should have been locked in the treatment cart and should not have been in the resident’s room. RN #15, the Certified Wound Care Nurse, stated the povidone iodine should have been kept inside the treatment cart and not in the room. The facility also failed to keep a medication cart free of loose pills and debris. Observation of West Wing Cart #1 revealed two loose pills with debris and trash in one drawer behind medication cards and one loose pill with debris and trash in another drawer, with the medication cards tightly packed in both drawers. Staff interviews stated each nurse was responsible for keeping the cart clean and organized, and the ADON and DON stated there should not be loose pills, dust from pills, or trash in the cart. The ADON also stated the medication cards were too tightly packed, which could cause pills to come out of the cards accidentally.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of supplemental oxygen for a resident, identified as R18, who was admitted with diagnoses including acute on chronic diastolic heart failure, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident's care plan required oxygen therapy, with a specific order for supplemental oxygen to be administered via nasal cannula at 3 liters per minute continuously. However, an observation revealed that the oxygen concentrator was set at 4 liters per minute, contrary to the physician's order. Interviews with nursing staff indicated a lack of consistent monitoring and adherence to the prescribed oxygen rate. RN 2 admitted that the oxygen rate should have been checked every morning, but it was not done on the day of the observation. RN 4, who worked the night shift prior to the observation, stated that the oxygen was set correctly at 3 liters per minute at the end of her shift. RN 3, who worked the day shift when the discrepancy was noted, claimed to have checked the oxygen rate and found it correct in the morning, but was unaware of any changes made later. The resident, R18, confirmed that they did not alter the oxygen settings themselves. The facility's failure to notify the physician or nurse practitioner about the increase in supplemental oxygen was also noted, as there was no documentation of such communication in the resident's progress notes. The Director of Nursing and the Chief Executive Officer/Administrator both acknowledged that nurses should follow physician orders and check oxygen rates during medication administration and resident checks. The nurse practitioner emphasized the importance of notifying medical staff if changes to oxygen levels were necessary to prevent dependency on supplemental oxygen.
Medication Error Rate Exceeds 5% Due to Non-Compliance with Insulin Administration Guidelines
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 34 opportunities, resulting in a 5.88% error rate. This affected one resident, identified as R63, during a medication pass. The facility's policy on medication administration requires that medications be administered as prescribed and in accordance with manufacturers' instructions. However, the facility did not adhere to these guidelines, leading to the observed errors. Resident R63, who has a medical history of type 2 diabetes mellitus, was involved in the medication errors. The resident was prescribed Lantus Solostar insulin and Humalog KwikPen insulin, with specific instructions for administration. During an observation, RN 7 administered 16 units of Lantus insulin without performing the required safety test, as per the manufacturer's instructions. Additionally, RN 7 administered Humalog insulin without priming the pen, contrary to the manufacturer's guidelines. Interviews with RN 7, the Facility Pharmacist, the Nurse Practitioner, the Director of Nursing, and the CEO/Administrator revealed a lack of adherence to the manufacturer's instructions and facility policies. RN 7 admitted to not following the priming instructions, believing it would waste insulin. The Facility Pharmacist and Nurse Practitioner emphasized the importance of following the manufacturer's instructions to ensure proper medication administration. The Director of Nursing and CEO/Administrator confirmed the expectation for staff to follow physician's orders and guidelines.
Inaccurate Insulin Dosage Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident diagnosed with type 2 diabetes mellitus. The resident, who was assessed as having intact cognition, was receiving insulin injections daily. The facility's policy required physician orders to be followed and reviewed to ensure proper care delivery. However, the Medication Administration History revealed discrepancies in the insulin dosages documented by an LPN. The LPN recorded incorrect dosages on multiple occasions, deviating from the physician's order of 35 units of insulin glargine. The LPN admitted to entering the wrong dosage in the electronic health record due to interruptions, despite knowing the correct dose. The facility's job description for charge nurses emphasized the importance of accurate charting and medication administration as per physician orders. Despite this, the LPN documented incorrect insulin dosages, which were not aligned with the active physician's order. The Director of Nursing expressed an expectation for accurate documentation in residents' medical records. This deficiency highlights a failure in maintaining accurate medical records and ensuring adherence to physician orders, as evidenced by the incorrect documentation of insulin dosages for the resident.
Inadequate Use of PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by staff when caring for a resident on enhanced barrier precautions (EBP). The resident, identified as R298, was admitted with a fracture and had a surgical incision and an indwelling catheter, necessitating EBP. The facility's policy required staff to wear a gown and gloves during high-contact care activities for residents on EBP. However, during an observation, a Certified Nursing Assistant (CNA) was seen emptying the resident's urinary catheter bag while wearing only gloves, contrary to the facility's policy. Interviews with the CNA, the Director of Nursing (DON), and the Chief Executive Director (CEO)/Administrator confirmed the expectation that staff should wear both a gown and gloves when providing care to residents on EBP. The CNA acknowledged the oversight, and both the DON and CEO/Administrator reiterated the importance of adhering to the facility's infection control guidelines. The deficiency was identified through a review of the facility's policies, the resident's care plan, and physician orders, which all indicated the need for EBP due to the resident's medical condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkwood Health & Rehabilitation | 2.3 mi | ★★★★★ | 9 | 0 |
| Essex Rehabilitation And Healthcare Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Park Terrace Health Campus | 3.3 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare At Rockford Rehab & Wellness | 3.6 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare At Summerfield Rehab & Wellne | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.